GERD: When medication isn’t enough

YOUR DOSE OF MEDICINE - Charles C. Chante MD () - August 22, 2004 - 12:00am
Heartburn! Maybe you’ve experienced it for so long that you can’t even remember when it began. Recurring heartburn is a sign of gastroesophageal reflux disease (GERD), caused by a weak lower esophagus. Luckily, antacids, as well as prescription and over-the-counter medications, offer relief for most sufferers. A small percentage of GERD sufferers (less than 5 percent), however, don’t respond to traditional treatments and must seek surgical intervention. Dietary modification, antacids and weight loss are the first steps in reducing and controlling GERD followed by acid-reducing medications, says AGA member, a gastroenterologist at Beth Israel Deaconess Medical Center, Boston, and associate professor at Harvard Medical School. If those aren’t effective, several tests can be performed to determine if surgery may be needed to provide relief. The most common test is an upper GI endoscopy, which takes five to 20 minutes. A small camera is passed through the mouth to provide an image of the inside of the esophagus. A local anesthetic spray numbs the throat and sedative medication can also be used to alleviate any discomfort during the test.

Other tests that may be necessary before surgery require the insertion of a tiny tube through the nasal passage and into the esophagus: esophageal manometry (one hour) gauges esophageal pressures, and a pH probe (24 hours) measures acid levels in the lower esophagus. The most common form of GERD surgery is called a laparoscopic Nissen fundoplication. This procedure requires general anesthesia.

Three of food half-inch incisions are made under the ribcage and above the navel. Guided by a small camera within the abdomen, the surgeon uses surgical tools to wrap the upper stomach around the lower esophagus and sew it into place. If a hiatal hernia (caused by a portion of the stomach slipping through the diaphragm muscle and up into the chest) is present it can be fixed also. (Noted: hiatal hernias and GERD are sometimes, but not always, associated). Surgery lasts three hours on average, followed by one to two additional hours in the recovery room. The patient is given an intravenous line for fluids and pain medication. A nasogastric tube is inserted through the nostril and into the stomach to prevent nausea, remaining a few hours or through the next day. A Foley catheter or urine tube may be used to collect and monitor urine. The hospital stay lasts one to two days. Death due to surgery complications is rare and is largely owed to complications from anesthesia. Don’t expect a guarantee of freedom from heartburn after the surgery. A study published in the Journal of the American Medical Association found that 62 percent of post-surgery patients were again taking heartburn medications within 10 years, but they experienced less severe symptoms and took medication less often.

Also, 16 percent needed a second surgery within 10 years to treat GERD or to correct complications from the first surgery, such as difficulty swallowing, intestinal gas and bloating. Because the procedure cannot be reversed easily, choosing a skilled and experienced surgeon is extremely important. A number of procedures for GERD that do not require incisions and use moderate anesthesia are being developed. Surgery is not a common treatment for GERD. However, it may provide relief for the minority who need an alternative to a lifetime of heartburn and continuous medication use.

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